What is a Team?

Team care integrates the skills of primary care providers and other health care professionals with those of the patient and family members into a comprehensive lifetime diabetes management program1,2 that is high quality and cost-neutral3 or cost-effective.4 Because most diabetes care is carried out by the person with diabetes or his or her family, the patient is the central team member.

Tools You Can Use

TeamSTEPPS for Office-based Care Curriculum. TeamSTEPPS® for Office-Based Care, developed by the Agency for Healthcare Research and Quality and the Department of Defense, offers techniques, tools, and strategies to assist health care professionals in developing and optimizing team knowledge and performance in an office-based care setting. The course is intended for practice facilitators—individuals who play a key role in leading and assisting practices with their quality improvement and practice transformation efforts.

Primary Care Team Guide. Developed by the Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), a national program of the Robert Wood Johnson Foundation, this guide presents practical advice, case studies, and tools from health care practices that have significantly improved care, efficiency, and satisfaction by transforming to a team-based approach.

Teams usually include health care professionals with complementary skills who are committed to a common goal and approach.5 Team composition varies according to patients’ needs, patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills. Teams may be physically located together or virtually connected through integrated and coordinated care processes.

To be optimally effective, teams may choose to develop a multidisciplinary planning and documentation tool for the medical record, which could include treatment goals, personal patient goals, and disease management, including medications, medical nutrition therapy, self-management education, and referrals. Such a tool can help all team members to clarify responsibilities, coordinate care, and communicate the patient’s progress in a timely way.6

Effective team models of care may include:

Building multidisciplinary teams (e.g., adding new team members such as diabetes educators, registered dietitians, social workers, psychologists, or pharmacists)

Expanding the professional role of an existing team member within the primary care practice setting (e.g., training nurses as health coaches or care coordinators, training medical office assistants to conduct pre-visit screenings)

Establishing small teams or “teamlets” led by physicians who are supported by one or more health care professionals, such as an advanced practice nurses, registered nurses, licensed practice nurses, medical office assistants, or care coordinators, to improve case management. For more information about “teamlets” see The Visit: Time with the Physician which features a “teamlets” section.

Expanding access to team care through non-traditional approaches to health care, such as telehealth, shared medical appointments, and group education.

Augmenting clinical care teams by linking to the resources and support of community partners such as school nurses, community health workers, trained peer leaders and others. For more information on partners in the community see Community Partnerships.

Creating Strong Team Culture. Developed by the American Medical Association as part of the STEPS Forward™ practice-based initiative, this module will help you to evaluate and improve team culture in your practice.

Building and sustaining an effective patient-centered diabetes team requires:

Commitment and support from organization leadership

Active participation from the patient and health care professional team members

Ways to identify the patient population through health information systems

Adequate resources

Payment mechanisms for team care services

A coordinated communication system

Documentation and evaluation of outcomes and adjustment of services as necessary

Patient satisfaction, quality of life, and self-management

You Can Do It

A Team-Building Model for Team-Based Care. Focusing on their strengths and borrowing concepts from family therapy helped bring this family medicine group together in pursuit of a common goal.
Marlowe DP, Manusov EG, Teasley D. A team-building model for team-based care. Family Practice Management. 2012;19(6):19–22.